1. PT20E Therapeutic Communications and Relationships PowerPoint #3

2. Course Objective #1 Define and describe the Psychotherapeutic Management Model according to the Diagnostic and Statistical Manual, (DSM) current edition.

3. Psychopathology Definition: the systematic study of mental disorders.

4. Psychotherapeutic Management Model Definition: Nursing care that balances the three (3) primary interventions used in care of D.D. and Psychiatric patients.

5. Psychotherapeutic Management Model Three (3) primary interventions: – Communicated Nurse-Patient Relationship (words) – Psychopharmacology (drugs) – Milieu management (environment)

6. Therapeutic Nurse-Pt. Relationship Communication skills

7. Psychopharmacology Psychotropic drugs:

8. Course Objective #4 Relate why a psychopharmacolo gic understanding is important for the psychiatric technician

9. Importance of Psychopharmacology Assess response Respond to side effects Evaluate for desired results Safely dispense Teaching Idiosyncratic reactions

10. Milieu Management Definition: Purposeful manipulation of the environment to promote a therapeutic atmosphere.

11. Course Objective #5 Define milieu management and its six elemental components

12. Milieu Management Components: – Safety – Structure – Norms – Setting limits – Balance – Environmental modifications

13. Safety Freedom from danger or harm

14. Structure Physical environment Regulations Schedules

15. Norms Expectations of behavior Promote community

16. Beliefs Truths held by a culture

17. Values Deep feelings that determine what is considered good or bad.

18. Norms Society accepted rules

19. Setting Limits Clear & enforceable limitations on behavior

20. Setting Limits – Behaviors: – Physical aggressiveness – Self-destructive acts – Lack of compliance – Use of alcohol or drugs – Elopement

21. Setting Limits Anticipate behavior!

22. Balance between Independence vs. Dependence Gradual process – too fast  – Overwhelmed

23. Environmental Modifications Changing the environment to promote mental health – Physical arrangement – safety issues – orientation features

24. Course Objective # 2 Describe the consequences of an imbalance in nursing care

25. Consequences of an Imbalance in Nursing Care Patient needs & setting Utilization Influence

26. Consequences of an Imbalance in Nursing Care All components must be present if pt’s. are to fully benefit

27. Consequences of an Imbalance in Nursing Care Imbalance  compromise tx

28. Course Objective #3 Relate the difference between therapy and being therapeutic.

29. Therapeutic vs. Therapy Education Therapy – graduate-level psychiatric training Therapeutic – undergraduate-level psychiatric nurses

30. Therapeutic Tasks Communication – Respect – Desire – Understanding – Active listening

31. Therapeutic Knowledge/skills Each encounter is part therapeutic milieu

32. Therapeutic Real! – Problems – Solutions – Practice situations

33. Therapeutic Consistent Spontaneous Informal Recreational

34. Therapy Cure or manage the course of mental disorder Trained Selective pt

35. Therapy Sessions – Formalized – On-going – Specific time, place, & length Specialized techniques

36. Therapeutic Nurse-Pt. Relationship Definition: A series of goal-directed interactions that focus on the patient – T, F, B’s – potential solutions Purposeful Unique

37. Therapeutic Nurse-Pt. Relationship Client challenges: – Communicating – Relating – Functioning

38. Role of the Psych. Nurse Identify problems Discover ways of meeting needs Experience relationship

39. Characteristics of the TxN-PR Planned Patient centered Goal directed

40. Brief Encounters Brief encounters – Process feelings – Validation – Feedback Quickly

41. Course Objective #21 & 22 List the stages of the therapeutic P.T.—patient relationships. Identify and describe the major tasks of each stage of the P.T.—patient relationship

42. Stages of TxNPR Orientation Stage Working Stage Termination Stage

43. Orientation stage Establishing trust and rapport Nurses learns – Concerns Patient learns – Role of the nurse

44. Orientation stage Create an environment – Honest – consistent, – keeps promises Clear, specific communications Confidentiality explained

45. Orientation stage Initiating conversations Non-confrontational

46. Orientation stage Establish a contract – Expectation – responsibilities

47. Orientation stage Gather assessment information – intake interview Needs coping strategies defense mech. recurring thoughts, feelings, behaviors awareness of problems ability and motivation to change

48. Orientation stage Gather assessment information Defining goals – Prioritize Needs Coping strategies Defense mech. Recurring T, F, B Motivate to change

49. Orientation stage Management of emotions: – Fear of losing control – Feelings – Anger

50. Orientation stage Feelings natural – Expression Empathy – Not alone – Hope

51. Orientation stage Palliative coping mechanisms – Rest – Nutrition – Exercise – Meditation

52. Orientation Stage Teaching healthy ways to meet emotional needs – Coping skills – Challenging negative self-images

53. Orientation stage Providing support: – Realistic hope Abilities Strengths – Worth – Non-judgmental – Dependence  independent

54. Orientation stage Providing structure: If the pt loses control – take temporary control If the patient is withdrawn – Spending time The major task of providing structure is – limit-setting

55. Orientation stage Crisis – Providing support – Managing emotions

56. Working Stage AKA: – Learning Stage – Change Stage Problem-solving – Work toward change – Stabilization

57. Working Stage Observation: – Describe the problem

58. Working Stage Observation: – Describe the problem – “Participant Observer” Nurses relationship

59. Working Stage Analysis: – Encourages accuracy in pts conclusions

60. Working Stage Interpretation: – Change is necessary – Explore solutions

61. Working Stage Planning: – formulating a plan – assists pts to solve their own problems – Encourage short-term, realistic, achievable, daily goals

62. Working Stage Testing out: – Trying out new behavior or solution in a safe environment first – Rehearsal

63. Working Stage Role playing – Practicing behaviors – Nurse plays the role of persons with whom pts are difficulty assess communication & behavior

64. Working Stage Evaluation – assess success

65. Working Stage Feedback – Constructive

66. Working Stage In-depth data collection: – Increased knowledge – Priority issues

67. Working Stage Reality testing: – Presenting another point of view

68. Working Stage Cognitive restructuring: – Cope with negative thoughts  – more realistic conclusions redefine reinterpret change perception

69. Working Stage Supportive confrontation: – Challenging pt’s contradictions, – It challenges pts to Meet their own needs Be accountable for their own – Feelings – Behaviors – Decisions

70. Supportive Confrontation Example: Pt: “I went out drinking only once last week. At least I’m trying to change.” Nurse: “I can appreciate your effort, but you agreed to abstain from alcohol completely.”

71. Working Stage Writing/journaling: – Tool – Release emotions – Objective Letters

72. Working Stage Promoting change: – Pt. initiated change – Support Family & friends Groups – Motivated

73. Working Stage Teaching new skills: – Desire + Know how – Small steps – Practice – Feedback

74. Termination Stage Evaluation & summary of progress: – ID changes – Long-term goals – Strengths & weaknesses

75. Termination Stage Synthesizing what has occurred: – Progress – Indirect outcomes of TxPNR – Encouraged other relationships

76. Termination Stage Referrals: – ID community resources – Written d/c instructions

77. Termination Stage Discussion of termination:

78. Continuum of Care Definition: – levels of care through which a pt can move depending on needs at the time

79. Course Objective # 25 List approaches and precautions to take with the following patient experiencing: Potential for violence, Hallucinating, Delusional, With conflicting values, With incoherent speech, Manipulative, Crying, That are sexually inappropriate, Uncooperative or in denial, Depressed/apathetic, Suspicious, Hyperactive, Transference

80. Special Approaches/Precautions Brief encounters

81. Violent Behavior Keep your distance Do not touch without approval Change the topic Suggest a “Time Out”

82. Violent Behavior Sit by the door – DO NOT BLOCK THE DOORWAY! Do not go into a room alone Leave temporarily – Be aware of self-injury potential Call for assistance

83. Hallucinations 1 st – Comment – Assess the content Powerlessness Hatred Guilt Loneliness

84. Hallucinations Do not focus on the hallucination – Activities &encounters “Do Not to act on commands” “Tell staff”

85. Delusions A fixed, false belief not consistent with the person’s intelligence and culture unamenable to reason

86. Delusions 1 st – Clarify the meaning – Rarely discussed Do not arguing Monitoring

87. Conflicting Values Nurses vs. patients Examine the effects of beliefs Perspective

88. Incoherent Speech Clarify Repeated questions  anxiety Frequent, brief support

89. Manipulation Means to gain attention, sympathy, control & dependence 1 st – Address – Limit-setting – Help pts. to directly express their needs

90. Crying Allowed & encouraged – Nrs – quite Stopped – Offer opportunity to talk

91. Sexual Innuendos or Inappropriate Touch Correct Discuss If continue – Limit-setting – Reassignments

92. Lack of Cooperation/Denial ID the cause – Disturbances in thought process – Lack of insight – Disagreement – Fear

93. Lack of Cooperation/Denial Discussed directly Trust Patience

94. Depressed Affect/Apathy/Psychomotor Retardation Acknowledge feelings but discourage rumination Encourage – personal care Postpone major decisions

95. Depressed Affect/Apathy/Psychomotor Retardation Patience Frequent contact Empathy

96. Suspiciousness Underlying – Fear Communicate – Clearly & simple – Avoid arguments – Rational Encourage participation – Do not force

97. Hyperactivity Decrease stimulation Physical activity Remain calm PRN meds?

98. Course objective #26 Compare and contrast transference and counter-transference

99. Transference (pt) Unconscious emotional reaction Patient  Nurse Based on past experiences

100. Transference (pt) Positive – if pts view the nurses as helpful and caring Negative – interfere with treatment

101. Countertransference (nurse) Unconscious emotional reactions – Nurse  patient – based on the nurse’s past experiences – sympathetic – unable to confront the pt appropriately

102. Interventions 1 st – Recognize 2 nd – Discuss – Gently & directly

103. Course Objective #27 Relate the nursing process to psychiatric nursing

104. What are the 5 steps of the nursing process? Assessment Diagnosis Planning Implementation Evaluation

105. Nursing process in psychiatric nursing… Patient centered Individualized

106. Course objective #29 & 30 Define and describe the following: Intake interview, Brief psychiatric rating scale, Nursing care plan, Process recording Define and give examples SOAP and narrative progress notes

107. Documentation Proof Law

108. Types of Documentation Progress Notes: – Assessing and analyzing communication skills, identifying pt themes, and evaluating the effectiveness of interventions

109. Types of Documentation S.O.A.P. Notes: – General narrative of basic nursing care provided to the pt

110. SOAP Charting S: Subjective Data: – What the pt says: “___” – Reported

111. SOAP Charting O: Objective Data: – Direct observation

112. SOAP Charting A: Assessment/Analysis: – interpretation – Conclusions – responses

113. SOAP Charting P: Plan: – Actions / treatments

114. Types of Documentation Problem-oriented Recording (POR) – description of a specific intervention, used for a specific problem and evaluates the pts response

115. P.I.E. Problem-oriented Charting P – Problem I – Intervention E – Evaluation

116. Types of Documentation Pt Care Plan: – Formal, written plan – Guides pt care Diagnosis Goals Interventions

117. Types of Documentation Special Procedures Documentation: – Interventions implemented – Timely – Expected level of care

118. Intake Interview Systematic Mental Status Exam (MSE) Assessments include: – Motivation to change – Coping strategies – Defense mechanisms – Recurring T, F, B’s

119. Course Objective #28 List key members for a psychiatric treatment team.

120. Treatment Team Psychiatrist: – MD – Specializes in psychiatry – Lead – Writes medical orders

121. Treatment Team Psychologist: – PhD in psychology – psychological testing – individual therapy

122. Treatment Team Clinical Social Worker: – D/C planning/placement – individual therapy – licensed

123. Treatment Team MFT’s: – Marriage and family therapists – Run groups – Individual therapy

124. Treatment Team Nursing Staff: – RN’s, LVN’s, PT’s: – manage the milieu – administer meds

125. Treatment Team Activity Therapists: – Leisure skill – Activity therapy groups

126. Treatment Team Occupational Therapists: – Training for work skills – ADL’s

127. Treatment Team Patient: – Participate

128. Encouraging Description of Perceptions Perceptions are unique so it is important to learn how each person perceives a feeling or interprets situations and events.